Horizon Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 1 when staff failed to assess the residents dialysis (a procedure where impurities or wastes are removed from the blood) access site within the standards of practice. The facility additionally failed to ensure R2 had an active physician's order that included the time, place, and days of their dialysis clinic treatments. Findings included: - R1's EMR from the Diagnosis tab documented diagnoses of dependent on dialysis and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated 05/04/26 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 had received hemodialysis during the observation period. R1's Urinary Incontinence and Indwelling CAA, dated 12/05/25 documented she had had feeling of urinary retention related to dialysis. R1's Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure pureed food (food has been ground, pressed, and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding) had been prepared to conserve the nutritive value, palatable flavor for two residents on a pureed diet. Findings included:- On 06/02/26 at 10:29 AM, Dietary CC washed his hands and put on a clean pair of gloves and stated there were two pureed diets in the facility but he would prepare three in case a resident wanted more. On the counter was a clean Robot Coupe food processor with a clean container, blade and lid. Dietary CC obtained a metal container from the warmer oven that contained three smothered pork chops. Dietary CC added the pork chops to the container and turned it on to begin chopping/processing the food. Dietary CC then went back to the oven to obtain the container of gravy. He placed the container of gravy on the counter and obtained a clean ladle to scoop out the gravy with and pour into the top of the lid to add to the chops. Dietary CC turned the Robot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 69 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to maintain an effective pest control program. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings include: - The outside vendor for pest control report dated 02/28/25 documented a captured rodent and suggested to the staff to keep doors closed at all times. The outside vendor for pest control report dated 03/13/25 documented staff members mentioned they saw a mouse; the vendor inspected the bait stations and no rodents were noted. The outside vendor for pest control report dated 03/27/25 documented no concerns from staff and none noted. This was the last date the outside vendor for pest control was at the facility. During an interview on 05/21/25 at 11:45 AM, Housekeeper Staff U reported there were rodents in the facility. She reported that she had to deep clean the residents ' rooms in March 2025 and said she found rodent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 69 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to promote a sanitary, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings include: - During the initial tour of the facility around 08:30 AM on 05/21/25, observation revealed there was flooring missing at the entrance of the dining room on the 300 hallways. Further observation revealed an area approximately four feet long by one foot wide that was covered with blankets which were saturated with water, and surrounded by cautionary wet floor signs on each side of the blankets. During an interview on 05/21/25 at 08:32 AM, Resident (R) 3, who had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition, reported he was concerned about the floor in front of the dining room that had water laying on top of all the blankets for about two weeks. R3 reported he did not feel safe as it was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 69 residents. The sample included four residents reviewed for elopement (when a cognitively impaired resident leaves the safe area or premises without supervision). Based on observation, interview, and record review, the facility failed to implement interventions to mitigate the risk of elopement for Resident (R) 1, when the facility failed to update the facility ' s Elopement Risk Book used to alert staff which residents were at risk for elopement. This deficient practice increased the risk of elopement for the affected residents. Findings included: - R1 's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) depression (excessive sadness), and traumatic brain injury (TBI-an injury to the brain caused by external forces). R1's Face Sheet in the EHR did not include a photo of the resident. R1's 04/29/25 admission Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 99. The MDS recorded R1 had moderately impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing a pneumonia caused by legionella). The facility failed to implement acceptable infection control practices when staff failed to properly store Resident (R) 48 and R60's oxygen tubing and nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help) in a sanitary manner. This deficient practice placed the residents in the facility at risk for infectious diseases. Findings Included: - On 02/11/25 at 03:35 PM, observation revealed R60 had an unbagged oxygen tubing and nasal cannula that was attached to the oxygen canister. The tubing and nasal cannula laid in the seat of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents who ate in the main dining room and resided in the 400 hall. This deficient practice placed the residents who ate in the main dining room at risk for impaired health and well-being; and the residents who resided in the 400 hall at risk for falls. Findings included: - On 02/11/25 at 11:29 AM, in the dining room and the 400 hall revealed the following issues: 1) The floor, approximately 18 inches (in) wide by five feet (ft) long, half an inch deep, located in front of the shower room on the 400 hall, had missing flooring down to concrete. The main dining room had the following: 1) The four floor vents with grayish-black fuzzy substance. 2) The two window air conditioners had the same substance. 3) The windows all around the dining room had numerous different-sized streaks of grayish-black areas on them. 4) Below the window air conditioner had approximately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness. Findings included: - On 02/11/25 at 08:20 AM, the kitchen, revealed the following: The walk-in refrigerator had a box of uncovered bacon and a box of roasted turkey breast on a shelf above a box of bulk pork sausage. Dietary Manager (DM) BB verified the finding and stated staff should cover food items before placing them in the refrigerator. DM BB stated staff should store thawing meat on the bottom shelf and discard the box of bacon in the trash. The outside of the ice machine, located outside the kitchen near the window to the kitchen where dirty dishes were placed, had numerous different-sized streaks of a whitish substance,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 66 residents. The sample included 17 residents, with five residents reviewed for immunizations, Resident (R) 24, R25, R29, R33, and R37, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, or obtain an informed declination, or a physician documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This deficient practice placed the residents at risk for pneumococcal infection and related complications. Findings included: - Review of R24, R25, R29, R33, and R37 clinical medical records lacked evidence the facility or the resident representative received or signed a consent or informed declination for the pneumococcal vaccine PCV20. On 02/13/25 at 01:30 PM, Administrative Nurse E stated residents are offered the pneumonia vaccines on admission and as indicated. Administrative Nurse E said the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 17 residents with one resident reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 18 with written information regarding the facility bed hold policy when she was transferred to the hospital. This deficient practice placed R18 at risk for not being permitted to return and resume residence in the nursing facility. Findings included: - R18's Electronic Medical Record (EMR) recorded diagnoses of Influenza A (an acute highly contagious viral infection of the nose, throat and lungs that causes the flu), acute respiratory failure (the respiratory system can not maintain normal levels of oxygen and carbon dioxide in the body, the condition is characterized by a relatively sudden onset of symptoms that are usually severe), hypoxia (inadequate supply of oxygen), cerebrovascular accident (CVA - stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 66 residents. The sample included 17 residents, with one Resident (R) 24 reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to implement a person-centered care plan with individualized interventions to address R24's post-traumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), trauma, triggers, and interventions to prevent re-traumatization. These deficient practices placed R24 at risk for decreased psychosocial well-being and ineffective treatment. Findings included: - R24's Electronic Medical Record (EMR) documented diagnoses of PTSD, major depressive disorder (a major mood disorder that causes persistent feelings of sadness), and traumatic brain injury (TBI - an injury to the brain caused by external forces). R24's Annual Minimum Data Set (MDS) dated 05/02/24 documented a Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview the facility failed to promote an environment free of hazards for Resident (R)21 who smoked cigarettes but was assessed for supervised safe smoking practices by the facility, however the resident revoked the assessment, and smoked without supervision. This placed the resident at risk for avoidable injuries and fire related hazards Findings included: - R21's diagnoses include cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), major depressive disorder (major mood disorder that causes persistent feelings of sadness), acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood), and pneumonia (a lung infection that causes inflammation and fluid or pus to fill the air sacs of the lungs). R21's Quarterly Minimum Data Set (MDS), dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 17 residents, with one reviewed for dialysis. Based on observation, record review, and interview, the facility failed to provide ongoing care plan communication and documentation of Resident (R) 70, who received dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) treatment, including updated care, and services required for R70. This deficient practice placed R70 at risk for inadequate care, complications, and health decline. Findings included: - R70's Electronic Health Record (EHR) documented R70 had a diagnosis of end-stage renal disease (decline in kidney function). R70's admission Minimum Data Set (MDS), dated 11/22/24, recorded R70 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded he required limited assistance of one staff for bed mobility, transfers, and toilet use. The MDS further recorded R70 as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 66 residents. The sample included 17 residents, with one Resident (R) 24 reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to R24's post-traumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). The facility failed to implement individualized interventions to prevent re-traumatization to R24. These deficient practices placed R24 at risk for decreased psychosocial well-being and ineffective treatment. Findings included: - R24's Electronic Medical Record (EMR) documented diagnoses of PTSD, major depressive disorder (a major mood disorder that causes persistent feelings of sadness), and traumatic brain injury (TBI - an injury to the brain caused by external forces). R24's Annual Minimum Data Set (MDS) dated 05/02/24 documented Brief Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 66 residents. The sample included 17 residents, with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported when Resident (R) 25's physician ordered insulin (a hormone that lowers the level of glucose in the blood) administration and finger stick blood sugar (a procedure that measures the level of sugar in a small drop of blood from the fingertip) had not been completed as ordered. This deficient practice placed R25 at risk for unnecessary medication administration and related complications. Findings included: - R25's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), hallucinations (sensing things while awake that appear to be real, but the mind created), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), major depressive disorder (major mood disorder that causes persistent feelings of sadness), diabetes mellitus (DM - when the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 66 residents. The sample included 17 residents with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure facility staff administered Resident (R) 25's physician-ordered insulin (a hormone that lowers the level of glucose in the blood) and obtained finger stick blood sugars (a procedure that measures the level of sugar in a small drop of blood from the fingertip) as ordered. This deficient practice placed R25 at risk for unnecessary medication administration and related complications. Findings included: - R25's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), hallucinations (sensing things while awake that appear to be real, but the mind created), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), major depressive disorder (major mood disorder that causes persistent feelings of sadness), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 66 residents. The sample included 17 residents with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 25, R38, and R22 had an adequate Centers for Medicare and Medicaid (CMS) approved indication for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. This deficient practice placed R25 at risk for unnecessary medication administration and related complications. Findings included: - R25's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), hallucinations (sensing things while awake that appear to be real, but the mind created), hemiplegia and hemiparesis weakness and paralysis on one side of the body), major depressive disorder (major mood disorder that causes persistent feelings of sadness), diabetes mellitus (DM - when the body cannot use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R) 10 flex pen, R68 vial of expired insulin (a hormone that lowers the level of glucose in the blood), and further failed to label R36 and R70 insulin flex pens when opened to use and when they expired. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On [DATE] at 08:10 AM, observation of the facility's 100 and 300 hall treatment carts revealed the following: -R10's Glargine (long-acting insulin) flex pen, was not labeled with an opened date or expired date. -R68's Levemir (long-acting insulin) vial, was not labeled with an opened date or expired date. -R36's Basaglar (long-acting insulin) flex pen with an opened date of [DATE] and an expiration date of [DATE]. -R70's Glargine flex pen with an opened date of [DATE] and an expiration date of [DATE]. On [DATE] at 08:15 AM, License…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 66 residents. The sample included 17 residents, with two sampled residents reviewed for hospice care. Based on observation, record review, and interview, the facility failed to ensure there was a collaboration of care between Resident (R) 38's hospice provider and the facility. This deficient practice placed R38 at risk of inadequate end-of-life care. Findings included: - R38's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (a progressive mental disorder characterized by failing memory and confusion), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), heart failure, and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R38's Significant Change Minimum Data Set (MDS) dated 01/08/25 documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 58 residents with five residents selected for review. Based on observation, interview, and record review, the facility failed to revise the care plan for Resident (R)1 for his pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) to his buttocks and placement of a urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag), for R2 for her right foot wound, and for R5 for catheter management. This deficient practice placed these three residents at risk to not receive appropriate cares and treatments. Findings included: - The Medical Diagnosis tab for Resident (R)1 included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), Down's Syndrome (chromosomal abnormality characterized by varying degrees of mental retardation and multiple defects), and muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 68 residents with three sampled residents for skin conditions. Based on observation, interview, and record review, the facility failed to ensure the staff provided treatments as ordered to Resident (R)2, who had an ulcer to her right foot, monitor her wound status weekly, and ensure she had pressure relieving boots in place when in bed. Findings included: - The Medical Diagnosis tab for R2 included diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), hemiplegia (paralysis of one side of the body) affecting right dominant side, dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) to bilateral (both) knees. The Quarterly Minimum Data Set (MDS) dated [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 68 residents with five residents reviewed, including three residents reviewed for urinary incontinence management. Based on observation, record review, and interview, the facility failed to provide timely incontinence care to Resident (R)1 and R2. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), Down's Syndrome (chromosomal abnormality characterized by varying degrees of mental retardation and multiple defects), and muscle weakness. The Significant Change Minimum Data Set (MDS) dated [DATE], assessed R1 with a short-term and long-term memory loss and impaired decision making. He did not reject care and was dependent on staff for toileting. R1 was always incontinent of bowel and bladder. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/12/24, revealed R1 had a memory problem making his decisions regarding tasks of daily life severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 68 residents with five residents reviewed, with one resident reviewed for pharmacy services, Resident (R)4. Based on observation, interview, and record review, the facility failed to ensure the staff ordered R4's medication timely, resulting in her missing eight doses of her scheduled Norco (narcotic pain medication) and one dose of her scheduled Fentanyl (narcotic pain medication) patch. Findings included: - The Medical Diagnosis tab for R4 included diagnoses of pain and restless leg syndrome. The Quarterly Minimum Data Set (MDS) dated [DATE], assessed R4 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. She required scheduled pain medication and received or offered and declined as needed (PRN) pain medication, had frequent pain or hurting in the past five days of the assessment period which effected sleep frequently and day-to-day activities at a level four on the zero to 10 pain scale, with 10 being the worst amount of pain. The Annual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 68 residents. Based on observation, record review, and interview, the facility failed to maintain an effective prevention and control program with failure to perform appropriate glove removal and hand hygiene during after a disposable brief removal and during a dressing change for Resident (R)3 on 07/29/24, lacked hand hygiene during peri-care for R2, stored R2's pressure reducing boot directly on the floor, and failed to ensure R5's catheter drainage bag positioned appropriately to ensure proper urine flow. Findings included: - The following observations revealed the following areas of concern: 1. On 07/29/24 at 01:28 PM, Certified Nurse Aide (CNA) N removed Resident (R)3's wet disposable brief with her gloved hands and picked up a new brief from an overbed table with the same gloved hands. LN I was in the room to perform wound care to R3's right gluteal (buttocks) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 70 residents. Based on observation and interview, the facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in resident areas including on five of the five resident hallways, the dining room, the beauty shop, and in courtyards, for the residents of the facility. Findings included: - Environmental tour of the facility, on 05/01/23 from 02:00 to 04:00 PM, with maintenance staff Z revealed the following resident accessible areas in need of housekeeping/maintenance services: 100 Hallway: The hallway lower walls, across multiple resident room entrances/doors, contained various sized areas of scraped off paint and gouges. The nurses' station/medication preparation room door stood open, and the coded door lock on it, lacked about half of the push-button numbers to the lock. The room had multiple areas over all the walls that lacked paint with scrapes and gouges into the walls. The wall inside to the left behind the medication cart, contained an electrical outlet which had one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 70 residents on five hallways, one being a locked dementia (progressive mental disorder characterized by failing memory, confusion) unit. Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services which included behavioral monitoring and staffing. The facility further failed to ensure adequate nursing staff to monitor medication administration as ordered by a physician, and to perform adequate monitoring of medications administered. Findings Included: - Upon entrance on 04/24/23 at 09:00 AM Administrative staff A informed the survey team the facility Director of Nursing (DON) quit two weeks ago, but the Minimum Data Set (MDS) nurse would be the acting interim DON. On 04/25/23 at 08:37 AM Certified Nurse Aide (CNA) I stated when both CNAs on the hall were performing cares on a resident who required two-person assistance, there was no staff left in the hallways to monitor the other residents on the hall (400). On 04/25/23 an anonymous resident stated it sure was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 70 residents, with 18 residents sampled. Based on observation, interview, and record review the facility failed on four days to have Registered Nurse (RN) coverage for at least eight hours daily in the last three months. Findings included: - The facility provided Census Report dated 04/24/23 noted 70 residents resided in the facility. On 04/24/22 at 07:30 AM, observation revealed 70 residents resided in the facility. Review of the nursing schedules for February 01, 2023, through April 24, 2023, documented four days with no continuous eight hours of RN coverage (02/11/23, 03/04/23, 04/09/23, and 04/15/23). On 04/27/23 at 10:30 AM, Administrative Staff A verified the facility lacked continuous eight-hour RN coverage for the four dates. She confirmed they had tried to cover every day. The facility's Staffing policy revised October 2017 lacked documentation of the RN coverage requirement. The facility failed to RN coverage at least eight hours daily for the 70 residents who resided in the facility, placing the residents at risk for unsupervised nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 70 residents. The facility identified three residents that received pureed meals from the main kitchen. Based on observation, interview, and record review, the facility failed to prepare and serve food in a sanitary manner to prevent the spread of food borne illnesses to the residents of the facility. Findings included: - On 04/26/23 at 11:00 AM, observation revealed Dietary Staff J pureed food for the noon meal. He brought five slices of ham over to the preparation area with no gloves on, and sliced the ham into small pieces. Without donning gloves, dietary staff J placed the cutting blade into the food chopper. He then donned on gloves and placed the ham into the food chopper, pureed the food, covered with foil and placed the pan of ham into the oven. He gathered his chopping equipment and placed the utensils in the dishwasher. Dietary staff J donned another pair of gloves and assembled the chopper. While wearing the same gloves, he opened the package of bread, reached into the package, and retrieved five pieces of bread and put into the chopper.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 70 residents. Based on observation, interview, and record review the facility failed to provide administrative services in a manner to effectively and efficiently use resources to attain/maintain each resident's highest physical, mental, and psychosocial well-being, for all 70 residents that resided in the facility. Findings include: - Upon annual health resurvey occurring on 04/24/23 to 04/27/23 and 05/01/23 to 05/02/23, the following deficient practices were found which demonstrate the lack of administrative services to effectively and efficiently use resources to attain/maintain each resident's highest physical, mental, and psychosocial well-being: The facility failed to protect the privacy and dignity of Resident (R)52 and R42. This deficient practice led to R42 being able to be around multiple other residents with visibly soiled clothing and R52 living in a malodorous environment. (See F550) The facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in resident areas…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 70 residents. Based on record review and interview, the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) committee meetings with the required members present, which included having the Medical Director present at the meetings. This had the potential to affect all residents. Findings included: - On 04/24/23 at 01:21 PM, Administrative Staff A provided sign-in sheets for quarterly QAPI meetings from November 2021 through March 2023. The facility lacked documentation for the required members at the meetings, with the Medical Director present at only in December 2021, February 2022, March 2022, and July 2022. On 04/27/23 at 03:44 PM, Administrative Staff A confirmed the facility failed to ensure the Medical Director attended required quarterly QAPI meetings The facility's Quality Assessment Assurance (QAA) Plan policy dated 11/08/22, documented that the administrator, the director of nursing, infection preventionist, and at least two other staff members must attend each meeting. The medical director shall always be a part…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 70 residents. Based on observation, interview and record review, the facility failed to maintain an effective infection control program with the failure of staff to perform hand hygiene when appropriate and failure of the staff to clean equipment between resident use. This deficient practice has the potential to negatively affect every resident in the facility. Findings include: - On 04/24/23 at 02:30 PM in the special care unit, Certified Nurse Aide (CNA) O carried her personal non-disposable cup and walked into a resident room to perform cares and came out of the room carrying a clear plastic bag that contained items with an unknown brown substance visible through the bag, in the same hand as her personal non-disposable cup. CNA O walked to the soiled utility room to dispose of the bag. CNA O continued to carry her personal non-disposable cup and went to perform cares on another resident then returned to the hallway without hand hygiene observed. On 04/24/23 at 02:45 PM, CNA O stated she performed hand hygiene inside the soiled utility room with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 70 residents. Based on observation and interviews, the facility failed to maintain an adequate call light system for the residents of the facility, when only two direct care workers had access to pagers to monitor for call lights, on the facility five resident hallways. Findings included: - On 05/01/23 at 03:00 PM, observation in the one hall nurses station, revealed the only facility monitor screen for the call light system in the facility. The monitor on the wall documented, Green, Unknown, Zone 45; Concord East- Main low battery failure; Concord West-Main low battery failure; and room [ROOM NUMBER] bed 2 resident, Repeated 6 times. At that time, Maintenance Staff Z reported no knowledge of the call light documentation or where Zone 45 would be. Staff Z referred the question to Administrative Staff A. Staff A reported she had to come to the facility recently (unknown date) to reset the system as it had Froze and those had been on the monitor since that time. Staff A continued…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 70 residents. The sample included 18 residents with one resident reviewed for bed side rails. The facility had 11 residents with bed side rails in place. Based on observation, interview, and record review the facility failed to monitor the use of bed side rails for Resident (R) 4. This deficient practice placed R4 and the other 10 residents at risk for potentially serious injury. Findings included: - R4's Electronic Medical Record (EMR) documented diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), acquired absence of the right leg below the knee (transtibial amputation that involves removing the lower leg), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The 05/28/22 admission Minimum Data Set (MDS), documented R4 had a Brief Interview for Mental Status (BIMS) score of six, indicating severely impaired cognition. The MDS documented R4 required supervision assistance of one staff for bed mobility, and transfers. The MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 70 residents, with 18 residents included in the sample. Based on interview and record review the facility failed to ensure sufficient competent staffing to address the behavior health needs of the residents to provide a safe environment. Findings included: - Review of R31's Physician's Progress Note, dated 04/24/23, documented the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), bipolar (major mental illness that caused people to have episodes of severe high and low moods), and depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The 04/18/23 Annual Minimum Data Set (MDS), documented, per staff interview, R31 had severely impaired cognition. R31 had inattention that would fluctuate, and physical and other behaviors towards…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R57's pertinent diagnoses from the Electronic Health Record (EHR) documented dementia (a progressive mental disorder characterized by failing memory, confusion) with agitation, other frontotemporal neurocognitive disorder (a progressive disease of the brain affecting the frontal and temporal lobes of the brain resulting in behavior outbursts, trouble communicating and base personality changes) and unspecified speech disturbances. R57's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) by staff assessment indicating memory problems with severely impaired cognition. No abnormal behaviors were documented during the seven-day look back period. The resident received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) daily during the seven-day look back period. R57's Quarterly MDS, dated 03/06/23 documented a BIMS by staff assessment indicating memory problems with severely impaired cognition. The resident had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 70 residents with 18 residents selected for review and included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure Resident (R) 50 and R57 were monitored for side effects of extrapyramidal (abnormal involuntary body movements caused by medications) symptoms due to antipsychotic (a class of medication used to treat psychosis and other mental emotional conditions) medication use, failed to monitor R25 and R48 for behaviors related to antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication use and antianxiety (a class of medications that calm and relax people with excessive anxiety, nervousness, or tension). Findings included: - R50's pertinent diagnoses from the Electronic Health Record (EHR) documented Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and generalized anxiety disorder (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 70 residents with 18 selected for review. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of Resident R42. This deficient practice led to R42 being able to be around multiple other residents with visibly soiled clothing. Findings included: - On 04/24/23 at 11:39 AM, R42 observed in a wheelchair in his room wearing pants that were visibly wet. R42 stated he was unable to get into the bathroom in his room, so he was going to try find one somewhere else. R42 self-propelled down the hallway, past two staff members, and into the dining area without staff intervention to change his brief or his pants. On 05/01/23 at 08:32 AM, Certified Nurse Aide (CNA) D revealed R42 normally wore briefs and was to be checked and changed every two hours. On 04/24/23 at 10:25 AM, a strong odor of urine was present halfway down the hallway in the special care unit, with the strongest odor noted outside R52's room. On 04/25/23 at 08:31 AM, a strong odor of urine was present in the hallway immediately outside of R52's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 70 residents, with 18 included in the sample. Based on observation, interview, and record review the facility failed to incorporate the recommendations from a Preadmission Screening and Resident Review (PASRR) level II evaluation report into Resident (R) 12's assessment, care plan, and/or a transition of care. Findings Included: - The Electronic Health Record (EHR) for R12 revealed the following diagnoses; anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), mild cognitive impairment (characterized both by a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life, such as communication, self-care, getting along in social situations and school activities), and schizoaffective disorder (mental health disorder characterized by a combination of symptoms of schizophrenia). The 01/17/20 Preadmission Screening and Resident Review (PASRR) Determination Letter informed R12 that the facility would provide and maintain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 70 residents with 18 sampled, including one for PASRR (Pre-admission Screening and Resident Review). Based on interview and record review the facility failed to inform the state mental health authority in a timely manner of Resident (R) 12's significant change on 10/14/22. Findings included: - Review of R12's medical record from October 2022 through April 2023 lacked notification to the state mental health authority regarding R12's significant change of 10/14/22, which included the placement of a feeding tube, and the increased need for assistance with activities of daily living. Review of the PASRR Determination Letter for R12 dated 01/17/22, indicated the resident had appropriate diagnoses to require a level II evaluation. On 04/27/23 at 02:15 PM Social Services Staff U stated she did not know she needed to inform anyone when resident's requiring a PASRR had a change in condition. On 04/27/23 at 03:33 PM Administrative Nurse B revealed she did not know how to answer the question. She confirmed the significant change had not been reported as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 70 residents with 18 residents included in the sample. Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for one resident of 18 residents reviewed for care plans. Resident (R) 216. Findings included: - Resident 216's physician orders dated 04/05/23 revealed the following diagnoses: fractured right fibula (broken bone), chronic obstructive pulmonary disease (COPD) - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), megaloblastic anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues). The Minimum Data Set (MDS) entry tracking documented the resident admitted to the facility on [DATE]. The five-day admission MDS, dated [DATE], revealed the resident had a brief interview for mental status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 70 residents with 18 included in the sample. Based on observation, interview, and record review the facility failed to provide timely care to skilled Resident (R) 216, who was in rehabilitation, with plans to return home. Findings included: - Resident 216's physician orders dated 04/05/23 revealed the following diagnoses: fractured (broken bone) right fibula (lower leg bone), chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and megaloblastic anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues). The Five-day admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) of 15, indicating intact cognition. The resident required extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 70 residents with 18 selected for review with two reviewed for incontinence. Based on interview, observation, and record review, the facility failed to provide appropriate treatment and services of Resident (R)42 through failure to recognize visibly soiled clothing related to urinary incontinence. This deficient practice had the potential to negatively affect R42. Findings included: - R42's significant change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R42 required extensive assistance of one to two persons for all cares. R42 was frequently incontinent of bladder. R42's quarterly MDS, dated [DATE] documented a BIMS score of 10, indicating moderately impaired cognition. R42 required extensive assistance of two or more persons for all. R42 was always incontinent of bladder. R42's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R42 was frequently…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 70 residents, which included 18 residents in the sample. Based on record reviews, the facility failed to ensure timely physician visits for Resident (R) 54, R43, and R25. Findings included: - R54 admitted to the facility on [DATE], but was not seen by the physician until 01/10/23, 98 days after admission. R54 was seen by the physician again on 04/05/23 and seen by the non-physician practitioner (NPP) on 10/11/22, 10/12/22, 12/07/22, 01/11/23 and 02/15/23. R43 admitted to the facility on [DATE], but was not seen by the physician until 01/10/23, 125 days after admission. The Electronic Health Record (EHR) lacked documentation of additional physician visits. R43 was seen by the NPP on 10/05/22, 10/19/22, 11/16/22, 12/14/22 and 01/17/23. R25 admitted to the facility on [DATE] and was seen by the physician on 07/22/22. The EHR lacked documentation of additional physician visits. R25 was seen by the NPP on 07/26/22, 08/03/22 and 08/10/22. The EHR lacked documentation of additional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 70 residents. Based on interview and record review the facility failed to ensure Certified Nurse Aides (CNA) received an annual evaluation for three of five staff reviewed to ensure the care provided to the residents for their highest practicable level of well-being. Findings Include: - Review of five Certified Nurse Aides (CNA) records (with employment for the facility documented as more than one year) revealed lack of documentation of annual evaluations for three of the five CNAs reviewed. (CNA L, CNA V, and CNA W). On 04/27/23 at 02:01 PM Administrative Staff A confirmed the facility was behind on the evaluations of the staff. The October 2017 facility Staffing policy lacked any direction/information/documentation that addressed the CNA annual evaluation. The facility failed to provide annual evaluations for three of the five CNAs reviewed to ensure the highest practicable level of well-being for each resident.

The facility census reported 70 residents with 18 residents sampled, that included five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow the physician's orders for Resident (R)50, related to physician ordered insulin. This failure placed the resident at risk for adverse effects related to medication use. Findings included: - R50's diagnoses from the Electronic Health Record (EHR) included diabetes mellitus, type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The 11/15/22 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of six, indicating severely impaired cognition. R50 received insulin injections five days in the seven-day look-back period. The 02/15/23 quarterly MDS documented the resident had a BIMS of 11, indicating moderately impaired cognition. R50 received insulin injections daily in the seven-day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.